Harm Reduction in Germany - The Frankfurt Way of Drug Care

Harm Reduction in Germany - The Frankfurt Way of Drug Care
Birgit Wichelmann-Werth, Lissabon April 1998

Dear Collegues,
first of all I would like to thank you for inviting me to this conference and I am honoured to have the opportunity to introduce you the practised Drug Treatment System of the City of Frankfurt.

Before doing so, I would first like to thank Dr. Luis Patricio and the organizers of this congress, whom presented here in Lisbon their opiate substitution program and for inviting me to this marvellous city during the spring season or should I say the later days of winter.

My name is Birgit Wichelmann-Werth, a terrible long name in Germany, wheras here in Portugal you are very familar with long names and in comparison, mine is short. I am a sociologist and family therapist and I have been working with drug addicts for eleven years. First I worked in a Counselling Center and now for six years as a Supervisor and manager in a low threshold multifunctional treatment center in the vicinity of the main train-station in Frankfurt, named "Café Fix". It was the idea of our clients to name the facility "Café Fix". "Fix" has a synonymous meaning in the German language. In common usage it means quick, and by the addicted it means "needle and syringe".

I was affiliated with the process of development in the harm reduction of drug users and their usage in Germany. Not only in theological means, such as writing several articles, conceptions and holding conferences but also in a daily practical way. I encouraged by means of force our needle exchange program, which started in 1988 and was a team-menber whom created the concept of "Café Fix".

The needle exchange program started in May 1988. First being a mobile program going with the usage of a small bus, we drove directly to here the addicts were. The team was composed of three social workers. Through this out-reach technique, we approached the drug users on their own territory (scene), changed needles and syringes, offered them free beverages (coffee and tee). This allowed us direct contact ans communication with the drug users, whom had no knowledge of our care system. With our mobile bus program from 1988 until 1990 and our move into our center ”Café Fix” we exchanged approximately 5 million needles and syringes.

To give you an impression of the development and achievement of our needle exchange program, I will give you a survey of our figures for the first year (1988), for the year 1993 and I will show you the statistic of the last year(1997).

In 1988 the total sum of distributed needles was 37 447. The sum of the received needles was 27 139. The sum of distributed syringes was 20 708 and of received syringes 18 872.

In 1993 the amount of changed needles and syringes reached a very high level. The sum of distributed needles was 556 810, received needles 545 091. The sum of distributed syringes was 365 188, of received syringes was 373 307. It was the year after destroying the open drug scene in the "Taunusanlage".

From this statistical overview you can see that the numbers still are decreasing. This is a result of the methadone treatment program and the change in consumption habits. From injecting to smoking.

Some times it was very hard to work there on the frontline of the open drug scene, but I confess, I was and I am fascinated by this job. I like our clients, better to say, most of them. I like the variety in this work. Communication with drug addicts, politicians, collegues from all over the world, police, district attorneys, journalists and so on. Since one year I am member of the Hessen Substitution Committee, which decides who can be treated with methadone at the expense of the Health Insurance Companies.

But now let me explain how we try to solve the problems caused by drug addiction. I mean, the problems of the individuals and the problems of the community.

Frankfurt is a town, situated in the center of Europe. It´s not the capital of the state of Hessen, one of the 16 states that create the Federal Republic of Germany, but it´s the biggest town with its 650 000 inhabitants. Just the same number are the commuters who are working in Frankfurt. The importance of the city is founded on the financial power. Frankfurt is the capital of national and international banking system. The importance also derives from the international airport, one of the most important and frequented airports of Europe. The significance as a junction is not only founded on the airport, but also on the large railway station, the crossing of several highways and the harbour. The highways lead from north to south and from east to west. This crossing of all traffic lines makes the city so important for the trade of money and goods. Goods of all kinds, legal goods and illegal goods as well. The conditions for trading are the same.

These are the reasons why Frankfurt has become a metropole of drugs since the early seventies. For a long time the synonyme for Frankfurt was "Krankfurt".It´s a play upon words. In German "krank" means ill. So the meaning of "Krankfurt" is Ill-City. There was no other town in Germany in the seventies and eighties where you could see heroin addicts so obviously consuming in the open space in the middle of the city. They used their drugs, they dealed with drugs, they loitered in the parks and the streets and around and between the marvellous skyscrapers of the insurance companies, as well as the mighty banks of Germany, such as the ”Deutsche Bank” and the ”Dresdner Bank”. Naturally the bankers and managers despised this misery and observed these ”elements of evil” with suspicion.

The second professional group which watched this meeting of outlaws with growing suspicion was the police. The figure of criminal delicts that was due to the group of drug addicts was growing steadily. In 1992 the number of lawsuits because of criminal delicts in relation with drugs at the district court of Frankfurt amounted to 1 871. The juridical system of the state and the city was permanently overburdend. Half of the prisoners were drug addicts and they were incarcerated because of their addiction of illegal drugs or because of criminal activities related to their addiction, such as burglary, theft or drug dealing.

The Drug Care system, which was constructed in Germany in the early seventies was based on the principles of detoxification and abstinence. It was organised in inpatient treatment centers all over the country and in psychiatric hospitals for detoxification. It was a good and efficient care system for those clients who devoted themselves and finished. About 30% of the clients were successful and lived a clean and integrated life after finishing therapy. Another 30% couldn´t get out of the triangle of addiction and crime and spent a lot of their lifetime in prison, the rest went back to the open scene. Some of them died of overdose, the others constitute the so called open scene. The open drug scene in Frankfurt grew till in the end of the eighties more than thousand addicts spent their days in the "Taunusanlage". This is the name of the park,where the open drug scene was. It was Frankfurt´s Platzspitz, the famous drug scene of Zürich in Switzerland. A void beyond law began to spread. But this was not the reason to change national drug policy in Germany which was based on repression and punishment. Just the opposite happened. Politicians called for more repression. In November 1992 the police raided and destroyed the open drug scene. But it was the epidemy of AIDS among drug users which initiated the chance of a change in politics at the end of the eighties.

This was the hour of birth for a new drug policy called harm reduction. Nowadays we look back on ten years in practicing this way. And I can say: It´s a successful way and it´s worth while to follow this course another ten years or more.When we started our harm reduction program, the figure of drug users in Frankfurt was estimated round about 10 000 people. That is 10% of the estimated 100 000 - 120 000 thousand of addicts of illicit hard drugs (heroin and cocain) in Germany. They were not only living in Frankfurt but also in the neighbouring towns Hanau, Offenbach and Wiesbaden. And you could draw a circle with a radius of 100 kilometres around Frankfurt from where drug users were attracted to buying drugs.That was because drugs were better and cheaper on the illegal market of Frankfurt.

Approximately 1000 drug addicts were living in the streets. They were homeless, had no job, had severe infectious deseases like TBC, AIDS and Hepatitis.

The first step we took, was the installation of three facilities of a new kind. In these Care Centers or contact points drug users were accepted with all the symptoms of their addiction. It was no longer a necessery precondition to quit with drugs in order to get support and help. Needle exchange programs had been installed before, now they expanded. New facilities were added, like emergency shelters, nutrition, medical treatment and counselling without precondition. All these facilities were situated in the main train station area, close to the open drug scene. This happened from 1990 to 1992.

The next, and I think decisive step, was the introduction of a methadone substitution program. In the Federal Republic of Germany up to that point of time only levomethadone was allowed.

The trade mark in Germany is L-Polamidon. It´s about twice as efficient and much more expansive than methadone. The municipal Board of Health was the first to start with a small program for only prostituting women. It started with 50 drug addicted women in 1989. But it took another three years until we could start the substitution program on a broader scale. It is based on two pillars. One is the installation of special multifunctional medical treatment centers, the so called "ambulances". We have four of them, three in the main train station area and the center of the city, one in the industrial area in the outskirts of the town. The second pillar are General Practicers who have a special training and concession to substitute drug addicts with methadone. The methadone treatment of heroin addicts is based on the so called NUB guidelines, (Neue Untersuchungs- und Behandlungmethoden or New Diagnostic and Treatment Methods) enacted by the German Committee of Physicians and Health Insurance Institutions in 1991.

These guidelines confirm that heroin addiction is not an indication for methadone substitution. It´s only allowed to substitute when methadone serves to cure other severe deseases like AIDS, Hepatitis, TBC and "similar severe deseases". Methadone can be given during pregnancy, birth and six days after delivery. In some cases it´s allowed to give methadone to prostituting women after sexual misuse, rape and violation. Hessen was the third state after Nordrhine-Westfalen and Hamburg, that started a broad methadone program. The numbers of substitution therapies increased fast. Nowadays we have 800 heroin addicts in substitution programs in Frankfurt, all over Hessen there are about 3000. Remember: in 1989 the number of persons in methadone treatment was 50. Multifunctional treatment centers with methadone substitution programs do exist only in Frankfurt and three other cities in Hessen with a big drug scene problem. All over the country the addicts depend on some 100 private doctors. The Hessen methadone treatment program is structurally based on an expert committee, the Hessen Substitute Commission. Each application for a therapie has to be issued to this committee, consisting of several General Practicers who have long experience in substitution, two social workers, one representative of the Hessen Committee of Physicians, one representative of the Municipal Health Board and one representative of the Health Insurance Companies. They decide whether methadone therapy is allowed at the expense of the Health Insurance Company.

Just in the beginning of this year, exactly on 1st of February, the setting has changed, because the applicable paragraph of law (10. Ausführungsverordnung der BtmVV.) has been renovelled. Now heroin addiction is an indication for methadone treatment. But in practice there are no consequences because the NUB guidelines which regulate the costs have not been adopted. May be they will, but I´m not sure about it because the financial situation of Health Insurance Companies in Germany is problematic (that´s a consequence of the reunion of western and eastern part of Germany). I think the Health Insurance Companies will try to avoid the costs and so they will look for a way to avoid more expensive treatments.

Taking the clients of our methadone treatment program in "Café Fix" as an example, I want to give you an impression of their situation in regard of their physical and mental health status and their social situation.

146 persons have been treated with methadone in 1997 in the ambulance of "Café Fix". 84 of them were men, 62 women, that is a percentage of 42,5%. From this figure we can learn that the methadone treatment programm is much more attractive for female drug addicts than other treatment programs, especially drug-free inpatient treatment. There you find only few women, sometimes only one or two in a group of 35 to 50 clients. The average age of male clients is 33,8 years, of female clients ist 34,2.

46 of the patients were HIV infected, 82 persons were Hepatitis B positive, 97 were Hepatitis C positive. Of those, who were HIV infected, 6 patients suffered from AIDS. They are treated with a combined anti-retroviral medication. Since 1997 the possibilities of medical treatment have become better because of the admission of new medicines on the German market. Nowadays we have 10 medicaments at our disposal for the antiretroviral treatment but our physicians in the amulance give only 8 of them in a combined modality because of difficulties in taking the pills and because of not wanted side effects. By the combination of these remedies it´s possible to decrease the virus load from millions under the limit of 500 per milliliter blood. That´s a decline of the virus copies about 99%. The patients feel better, they are able to leave hospital and to live again. Our physicians of the ambulance are working very close with the infectious ward of the Frankfurt University Hospital. In our daily work we profit a lot by the medical research that is done in concern of HIV and AIDS in some Institutes in Frankfurt. There is a lot of research in the HIV Infectious Ward, House 68 of the University and in the Paul-Ehrlich-Institute too. So we are lucky to have a good relationship between the practical experts and the researchers. Our clients will profit from this circumstance. They are much more better treated than in other parts of the state, especially in the rural countryside.

As it´s known by the international publications, a lot of drug addicts are suffering from severe psychiatric deseases. Therefore, after 5 years of pioneer work in methadone treatment, we started a new phase of better diagnosis and treatment enhancement for our patients. In 1997 we hired a psychiatrist and she diagnosed all our patients who were in medical treatment at that moment. The result was an affirmation of our hypothesis. 38% suffered from a mental illness as psychosis, schizophrenia and boarderline symptoms. 26% suffered from depressions combined with suicidal tendencies. Although we took one more step, the situation is not satisfying at all. There are only few psychiatrists who are willing to treat our patients and we have no specialised housing projects for these clients with a dual diagnosis.

Me and my social worker collegue, we wrote a conception for such a housing project, where 12 clients could live and work as long as they want, may be lifelong. The staff has to be combined multiprofessional and big enough, so that a professional is in duty at any time, day and night. A psychiatrist has to be responsible for the medical treatment of the clients, social workers have to do the organisation, solve the conflicts with the social institutions and the neighbourhood. Nurses should be in the team and psychotherapist too.We want a farmhouse with a big garden and buildings for an employment project on the outskirts of Frankfurt. For these clients we need both, the infrastructure of the city and the calmness of the countryside. I like this conception very much. I can see the house before my eyes. It would be a good alternative to the life of stress in the streets of Frankfurt but in the moment we have no possibility to realise the conception because of inadequate funding. So it will remain on paper for the next time.

The social situation of the clients is characterized by dependency on social welfare, unemployment, bad education, lack of money, lack of family relationships and friends. Most of the social relations are more conflictive than protective. So the task of psychosocial care is multidimensional. In the pioneer phase it was the problem of homelessness that was to be solved. In a research which we made in 1993 30% of our clients were living in the streets or sleeping in an emergency shelter. You can imagine that therefore solving the housing problem was the most urgent task for the social workers. Reaching a figure of 16% homeless clients in 1997, I can say we were succesful in doing this job. Those who are still living in the streets of Frankfurt are the most severe cases, especially the clients with a dual diagnosis.

In 1993 only 26% lived in their own apartment, in 1996 49,6% and in 1997 59,6%. The others are living with their parents, 6,2%, or in special housing projects for substituted people, 10,3%. Looking at these numbers we can´t say, that the problem is solved but the situation is considerably better than 5 years ago.

The next problem is unemployment. Only 4% of the clients have a fulltime job and can live from their wages. All the others are dependent from social welfare or from unemployment benefit. The economic crisis with nearly 5 million unemployed people in Germany is a structural factor which obstructs an integration and rehabilitation. But on the other side, social integration without a job is not complete. Starting a methadone treatment program for our clients had the meaning of losing a job, namely being on the open drug scene, chasing money and drugs all the day. Concerning this, the methadone treatment makes our clients unemployed.

Therefore we started an employment project in "Café Fix" in 1991. First we created only two or three jobs for our clients. It was an experiment. Between 1992 and 1995 we enlarged the employment project because there was a great demand for these jobs. They were attractive because they were reachable for our clients. Nowadays we have 20 jobs within our facility, another 10 jobs outside in other facilities of our organisation and with cooperation partners. Our best jobs are in the famous "Frankfurter Palmengarten" one of the most important botanic gardens in the world. The director of the "Palmengarten" is a very engaged woman with a warm heart and social consciousness. We have six working places there. Four for clients who want to try to work again after a longer time of being unemployed. They have to work 4 days a week, each time 4 hours. The other two are fulltime jobs for clients who have been successful in fulfilling the 4 hours job for half a year and who are able and willing to do fulltime work. There are only few a of our clients, who are able to fulfill a fulltime job. Most of them are too sick and too unstable.

The other jobs are in our hygienic area, showers, laundry and clothing chamber. In the kitchen, as haircutter, as housekeeper and so on. By integrating these jobs in the facility we reached two goals:

1) create an employment project for our clients. 2) increase the services offered in "Café Fix". The employment project was the only possibility for the clients to earn money legally. Working creates self-confidence and self-determination. It makes them feel better, structure their days and help them to refind and develop abilities which are helpful in daily life. Without our client workers a lot of service offerings would not exist, e.g. the hygienic area and the daily emergency shelter.

There is no time limit for working in the project. In the beginning we never supposed that the clients would stay for such a long time. So we didn´t care about this issue. But last year we realised that some jobs were occupied by the same clients since three or four years. So we discussed the issue in one of our team meetings. Although there are some good reasons for a time limitation (40 clients on a waiting list, lack of pressure can invite clients to persevere), we decided against a limit. The main reason for this decision is that our clients have no chance in the momentary situation in the job market in Frankfurt. There would not be any sense in giving them a job for one or two years, integrate them on a low level of the job market and then push them out again. If there will be a change in the job market in the future we will have a new discussion and may be make another decisions.

We pay 13,-- DM per hour in cash and for each working day, they will get a free dinner from our kitchen. The payment is made by our secretary two times a week, on Monday and on Thursday. But each person is allowed to come one time a week for payment. So we try to teach our clients to be careful with their money. First we had a lot of trouble because some of them tried to get money two times a week but they have learned that it´s not worth while to make troubles because they won´t make ends meet. The highest amount is 530,-- DM per month. This is caused by two facts. First we have to stay under the limit of social welfare allowances, second reason is that we have a sum of 90 000,-- DM for the whole employment project per year and we want to employ many clients.

Another possibility of payment is do community services instead of being penalized by the courts.

Some of the clients have to work hundreds of hours in community service or they will be arrested.

There are only few possibilities, where drug users or clients in methadone treatment can do this in Frankfurt. It´s necessary to have the admission of jurisdiction. And you only get this if you are reliable. Most of the other institutions and facilities with the admission to work with people rendered community services are not experienced and don´t want to work with drug addicts. So there are a lot of clients waiting. There are only few projects like ours in Germany.

In summer 1997 I organized a coneference in cooperation with FDR ( Fachverband Drogen und Rauschmittel). That´s the committee of the German Care System for Drug Addicts. There was great interest in the conference 30 representatives of facilities all over Germany met and discussed the problems but it was obvious that there was little or inadequate information and experience in this issue. Only 8 - 10 projects like hours do exist, all the others are working with abstinent clients.

We are now writing a new conception for a larger employment project because we think that it will not be possible in the next future to integrate our clients in the so called first market of labor. But on the other hand we made the experience that labor is one of the most important factors of reintegration. We want to create new jobs for 20 clients outside of "Café Fix". Jobs for those who have taken successfully the first step in our employment project, who are reliable and work continuously and who want to work for their own wages and become independent from social welfare. To create our new project we need a lot of money and as I told you we can´t expect more money from the municipality, therefore we are forced to raise funds. For Germany that´s a new model and we are not used to it. So we have to make new experiences and I think it will take considerable time until we have enough money to start our project.

In addition to "Café Fix" we created in 1994 a therapeutic residential project for 14 clients of our ambulance who are treated with methadone and before living in the streets or in emergency shelters. It´s situated in a very good district of Frankfurt in a nice old house. Only ten minutes away from "Café Fix" but in another world. The main objective of social work which is done in this therapeutic resident project is to enable the clients to get and to hold their own appartment. 22 clients out of the total sum of 70 clients who lived there between May 1994 and December 1997 have reached this objective.

The third and up to now last step is the installation of the four so called "Health Rooms" or "Druckräume". These are facilities for i.v. drug users to prepare and inject their drugs in a room under surveillance of a staff which is trained for emergency situations. The rooms are hygienically clean. The objectives are to avoid stress, infectious deseases and death by overdose.

The clients can get everything they need to inject, sterile needle and syringe, distillated water, a clean spoon, a filter, ascorbin acid and a candle, everything except heroin. This decisive material they must buy on the illegal market. With the bad quality of street heroin involves the source of complications and that of risk. There is only 5% up to 12% pure heroin on Frankfurt's street market. The addicts never know it´s quality until they have injected it.

The entrance to the "Health Rooms" is allowed only for people who are well known by the staff or who are obviously heroin addicts. Entrance is not allowed for youngster under the age of 18 years. That is inforced by a special law in Germany that is for the protection of youngsters. So it´s not allowed to sell alcohol to kids younger than 18, not in shops nor in restaurants. And it´s also not allowed to sell cigarettes to kids under the age of 16.

Next step should be the installation of a controlled heroin prescription program. The municipality of Frankfurt applied for such a project in 1994 but it could not start until now. The reason is of contradiction in the politcal area. We still have very conservative and repressive politics in our Federal Government. Without consent of the Ministry of Health it will not be possible to begin such a program. So we are waiting for the election in autumn of this year. Maybe with a new government new steps in drug policy will be possible.

But even without a heroin prescription project we can put on record that the way of harm reduction which we follow since 1990 is a successful way.

The number of deaths caused by drug overdose declined from 147 in 1991 to 22 in 1997.

The rate of HIV infection is estimated on 25 - 30% of all i.v. drug users in Frankfurt. A small rate in comparison with other towns with a similar drug scene. For example Marseille has an estimated rate of 70% HIV positive drug addicts. According to an article in the British Medical Journal Lancet from June 1997 researchers of the University of Melbourne have proved that the supplying of free needles and syringes have decreased the rate of HIV infections. In towns with needle exchange programs the infection rate has decreased about 5,8%. In towns without such programs the infectious rate has increased about 5,9%.

In regard of criminality the situation has become better. The number of lawsuits related to drugs usage, has declined from 1 691 (1995) over 1 431 (1996) to 878 (1997).

The number of drug users with first police contact declines about 12,3% and the average age of drug addicts increases up 31 years. A sign, that fewer young people have started with heroin consumption.